“治之以兰，除陈气也”理论视角下肥胖合并2型糖尿病的病机与治疗探析

An Analysis of the Pathogenesis and Therapeutic Strategies for Obesity with Type 2 Diabetes Mellitus from the Perspective of the “Removing the Stale Qi with Lan” Theory

摘要: 肥胖合并2型糖尿病是当前临床常见的代谢性疾病组合，其核心病理基础涉及胰岛素抵抗、胰岛β细胞功能减退、脂质异位沉积、慢性低度炎症及肠道菌群失衡等。中医学虽无“肥胖合并2型糖尿病”之病名，但可归属于“肥胖”“消渴”“脾瘅”等范畴。《素问·奇病论》提出“治之以兰，除陈气也”，其原文针对“口甘”及“肥美所发、转为消渴”的病机，过食肥甘厚味，损伤脾胃，致脾失健运，水谷不化精微，反生湿浊；湿浊内蕴，日久郁而化热，热灼中焦，壅滞气机，津液不得上承、布散失司，发为消渴。本文以“陈气”为切入点，探讨肥胖合并2型糖尿病“脾失健运为本、痰湿脂浊为标、郁热瘀阻为变”的病机演变，并阐释“以兰除陈”在芳香化浊、醒脾运中、疏畅气机、祛湿和胃等方面的理论内涵。在此基础上，提出以“减积、化浊、调枢、护胰”为基本治疗思路，强调饮食运动干预、体重管理及中西医协同治疗。本文认为，“治之以兰，除陈气也”并非单纯使用某一芳香药物，而是体现了针对肥甘积滞、湿浊壅塞和中焦气机不利的治疗原则，可为肥胖合并2型糖尿病的中医辨治与临床研究提供理论参考。

Abstract: Obesity combined with type 2 diabetes mellitus (T2DM) is a prevalent metabolic disorder in clinical practice, characterized by insulin resistance, pancreatic β-cell dysfunction, ectopic lipid deposition, chronic low-grade inflammation, and gut microbiota dysbiosis. Although this condition lacks a direct equivalent in traditional Chinese medicine (TCM), it can be classified under the categories of “obesity,” “Xiaoke” (wasting-thirst), and “Pi Dan” (spleen-heat). The Suwen·Treatise on Extraordinary Diseases states: “Treat it with Lan, remove the stale qi,” addressing the pathogenesis of “sweet taste in the mouth” and the progression from “excessive consumption of rich and sweet foods” to “Xiaoke.” According to this theory, overconsumption of rich and sweet foods damages the spleen and stomach, leading to spleen failing in transportation and transformation, failure of the essence of water and grain to transform, and the generation of damp turbidity. Prolonged damp turbidity transforms into heat, which scorches the middle energizer, obstructs qi movement, and impairs the distribution of body fluids, ultimately resulting in Xiaoke. This paper, taking “stale qi” as a conceptual entry point, explores the pathogenesis of obesity with T2DM, characterized by spleen dysfunction as the root, phlegm-damp and lipid turbidity as the manifestations, and heat stasis as the complication. It further elucidates the theoretical implications of “using Lan to eliminate stale qi” in terms of aromatic transformation of turbidity, awakening the spleen, unblocking qi, and harmonizing the stomach. Based on this framework, a treatment strategy of “reducing accumulation, transforming turbidity, regulating the pivot, and protecting the pancreas” is proposed, emphasizing dietary and exercise interventions, weight management, and integrated Chinese and Western medicine approaches. This paper argues that “treating with Lan to remove stale qi” is not merely the use of a specific aromatic herb but embodies a broader therapeutic principle targeting excessive diet-derived accumulation, damp turbidity obstruction, and middle energizer qi stagnation, thereby providing a theoretical reference for TCM pattern differentiation and clinical management of obesity with T2DM.